NWT Clinical Practice Guidelines for Primary Community Care Nursing - Women’s Health and Gynecology

Dysfunctional Uterine Bleeding (DUB) Definition Menorrhagia may signify a bleeding disorder or a Abnormal uterine bleeding not caused by pelvic structural lesion, such as uterine leiomyomas, pathology, medications, systemic disease or adenomyosis or endometrial polyps. pregnancy. It is the most common cause (in 90% Up to 20% of adolescents who present with of cases) of abnormal uterine bleeding but is a menorrhagia have a bleeding disorder such as von diagnosis of exclusion. Willebrand's disease. Liver disease with resultant coagulation abnormalities and chronic renal failure Causes may also cause menorrhagia. Usually related to one of three hormonal- imbalance conditions: estrogen breakthrough Polymenorrhea is usually caused by an inadequate bleeding, estrogen withdrawal bleeding and luteal phase or a short follicular phase. progesterone breakthrough bleeding. Oligomenorrhea in an ovulating woman is usually Anovulatory Dysfunctional Uterine caused by a prolonged follicular phase. Bleeding Anovulation is the most common cause of DUB in Intermenstrual bleeding may be caused by cervical reproductive-age women. It is especially common disease or the presence of an intrauterine in adolescents. Up to 80% of menstrual cycles are contraceptive device. anovulatory in the first year after menarche. Cycles become ovulatory an average of 18-20 Midcycle spotting may result from the rapid months after menarche. decline in estrogen levels before ovulation.

Some women still have anovulatory cycles after For other causes of abnormal uterine bleeding, see the hypothalamic-pituitary axis matures. Weight Table 2, above, this chapter. loss, eating disorders, stress, chronic illness or excessive exercise may all cause hypothalamic History anovulation. • Age (e.g. reproductive age or menopausal) • Amount, duration, frequency, interval of Another cause of anovulation is polycystic ovarian bleeding disease. This unopposed estrogen state increases • Try to determine if cycles are ovulatory or the risk of endometrial hyperplasia and cancer. anovulatory (see Table 3, this chapter) • Date of last normal menstrual period Some women with chronic anovulation do not fall • Any contraception use (type, how used) into any of the above categories and are • Hormone replacement therapy if considered to have idiopathic chronic anovulation. postmenopausal • Possibility of pregnancy All causes of anovulation represent a • Signs of easy bleeding (e.g. gums) or bruising progesterone-deficient state. suggestive of coagulopathy • Any pain associated with bleeding Ovulatory Dysfunctional Uterine • Past history of gynecological problems such as Bleeding abnormal Papanicolaou (Pap) smear, fibroids, Although less common than anovulatory bleeding, sexually transmitted diseases (STIs), ovulatory DUB may also occur. DUB in women gynecological malignancy, prior episodes of with ovulatory cycles occurs as regular, cyclic abnormal uterine bleeding bleeding. • Past history of thyroid, renal or hepaticdisease • History of strenuous physical exercise (which may cause DUB)

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• Eating disorder, significant emotional or A full gynecological examination, including psychological stress determination of blood pressure and weight and • Date and result of most recent Pap smear examination of thyroid, breasts, abdomen and • Date and result of most recent mammography pelvic area (bimanual), should be performed.

Physical Findings The pelvic examination consists of careful DUB is a symptom, not a diagnosis. The findings inspection of the lower genital tract for lacerations, are variable, depending upon underlying cause. vulvar or vaginal pathology, and cervical lesions The results of the examination may be deceptively or polyps. Bimanual uterine examination may normal or obviously abnormal. reveal enlargement from uterine fibroids, adenomyosis or endometrial carcinoma.

Table 3: Characteristics of Ovulatory and Anovulatory Menstrual Cycles Feature Ovulatory cycle Anovulatory cycle Cycle length Regular Unpredictable Premenstrual symptoms Present None Bleeding Dysmenorrhea Unpredictable bleeding pattern; frequent spotting; infrequent, heavy bleeding Breasts Tender Non-tender Basal temperature curve Biphasic Monophasic Other Change in cervical mucus Mittelschmerz

Differential Diagnosis whom there is no response to initial management See Table 2, in "Abnormal Uterine Bleeding," strategies. above, this chapter. These tests would be ordered by a physician. Diagnostic Tests • Urine pregnancy testing for all patients of Endometrial biopsy and ultrasonography should be reproductive age performed early in the investigation of bleeding in any postmenopausal woman. • Complete blood count (to provide a measure of blood loss and adequacy of platelet count) • Prothrombin time (PT) and partial Management thromboplastin time (PTT) Goals of Treatment • Levels of thyroid-stimulating hormone (TSH) • Rule out organic pathology and prolactin • Regulate menstrual cycles • Liver function tests (ALT and total bilirubin) • Prevent complications • Cervical and vaginal samples for culture • Pap smear Specific management depends on the underlying cause. • Pelvic ultrasonography if organic pathology is suspected Premenopausal Women If the reproductive-age woman is not pregnant, the Refer for endometrial biopsy early in the results of the physical examination are normal, and investigation of any woman who is > 35 years of all pathologic, structural and iatrogenic causes age, postmenopause, or who has a history of have been excluded, abnormal uterine bleeding is prolonged exposure to unopposed estrogen in

September 2004 Dysfunctional Uterine Bleeding (DUB) - Adult 2 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Women’s Health and Gynecology usually dysfunctional in nature and can be endometrial carcinoma. Of all postmenopausal managed with hormonal therapy. See Table 4, women with bleeding, 5% to 10% are found to below, this chapter. have endometrial carcinoma. Other potential causes of bleeding are cervical cancer, cervicitis, Postmenopausal Women atrophic vaginitis, endometrial atrophy, The most serious concern in postmenopausal submucous fibroids, endometrial hyperplasia and women with abnormal uterine bleeding is endometrial polyps.

Table 4: Pharmacologic treatment for dysfunctional uterine bleeding Age group Treatment* Comments Premenopausal OCP Low-dose (35 mcg) monophasic or triphasic OCP can regulate cycles while providing contraception

medroxyprogesterone 10 mg PO od for If contraception is not an issue, medroxyprogesterone can 10 days be used to regulate cycles; in a woman who has or amenorrhea or oligomenorrhea, medroxyprogesterone medroxyprogesterone 150 mg IM every 3 months can protect against endometrial q3months hyperplasia Perimenopausal medroxyprogesterone 10 mg PO od for May be used monthly to regulate bleeding pattern 10 days Usually use 20 mcg pills; OCP can be continued until the OCP woman has finished menopause, then change to HRT (OCP may be relatively contraindicated in women > 35 years of age who smoke) Postmenopausal Cyclic HRT May consider increasing the progesterone dose if early (receiving withdrawal bleeding occurs; increase estrogen dose if HRT) intermenstrual bleeding is present

Continuous combined HRT (B class May increase the estrogen dose for 1-3 months to drug) stabilize endometrium; may also try increasing the progesterone dose; if bleeding continues, consider With continuous combined HRT, up to changing regimen to cyclic HRT or using a different type 40% of women have irregular bleeding of estrogen in the first 4-6 months of therapy (Rubin et al. 1996). Bleeding is more common when hormone therapy is started less than 12 months after menopause occurs. * hormonal drugs used as treatment for DUB and not as contraceptives are all B class drugs

Women Receiving Hormone interactions or malabsorption. If unscheduled Replacement Therapy bleeding occurs in two or more cycles, further Women receiving hormone replacement therapy evaluation is indicated. often present with abnormal bleeding and of these, 30% have uterine pathology. Other causes include Appropriate Consultation cervical lesions, vaginal pathology or the hormone Consult a physician before ordering diagnostic therapy itself. tests and for medication treatment options if urgent treatment is warranted. Women receiving sequential hormone replacement therapy may experience midcycle breakthrough bleeding because of missed pills, medication

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Monitoring and Follow-Up Referral • Follow up monthly until cycles have become • Refer electively any client (if she is stable) to a regular physician for thorough evaluation and treatment. • Monitor hemoglobin as needed if heavy bleeding continues despite therapy

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